What is Practising Holistically?

What is Practising Holistically?

To practise holistically is to operate in physical, psychological, socioeconomic and cultural dimensions, taking into account feelings as well as thoughts.

It’s important because it gives you an ‘all-rounded’ picture of what is going on and in so doing, helps you truly understand the impact of a medical problem on an individual’s world. And once you understand that, you can understand what the priorities might be for the patient (in addition to understanding your own ‘doctor’ priorities).

So, what’s ICE and PSO got to do with it?

ICE and PSO are two simple microskill tools that can help you explore the holistic side of things in more detail.

ICE is an acronym for Ideas, Concerns and Expectations.

Ideas – what is the patient thinking/feeling?

Concerns – what is the patient worried about?

Expectations – what is the patient hoping for at the end of the consultation?

PSO is an acronum for Psycho-Social-Occupational.

Psycho – psychologically, how is the medical problem affecting the patient?

Social – Socially, how is the medical problem affecting the patient?

Occupational – how is the medical problem affecting the patient occupationally?

Firstly, sometimes patients don't tell you everything straight away..

Remember, not all patients tell you everything straight away

Yes, it’s true. Many patients won’t tell you everything straight away, especially when you’re exploring their ideas, concerns and expectations (ICE). If you ask them directly about their ICE at the beginning of the consultation, they may just say “nothing really” or shrug their shoulders. Nearly all patients will have some ideas, concerns or expectations but they don’t share them straight away because…

It is sensitive territory. Sensitive areas require some rapport-building first before people are willing to divulge information more freely.

Some patients worry that their ideas, concerns and/or expectations might look stupid to the doctor and they don’t want to look stupid in front of the educated doctor. (understandably)

Some patients are embarrassed to divulge their ideas, concerns and/or expectations.

Some patients don’t know how to vocalise what they want to say and need help from you.

Here are some tips to get patients to open up

Try and ask about ICE a little bit into the consultation when you have managed to develop some rapport. So be nice and be attentive. Show them you want to help.

A patient is more likely to divulge information if you also create an atmosphere where their input is more than welcomed. So, be nice, kind and compassionate.

Tell them how important their opinions matter.

Tell them that in order to understand them better that you’d like to know what they think.

And of course, always reassure them if they say “I don’t want to sound silly”.

An example

In a consultation, if a patient says ‘nothing really’, consider re-framing and re-phrasing your question and perhaps ask it a little later on once rapport has established itself more fully. For instance….

Doctor: “And have you had any thoughts as to what might be going on?”

Patient: “not really” (PS not really means yes!!)

Doctor: “Not really? Sounds like there might be something?”

Patient: “Well it might sound silly but I was talking to my friend and she said….”

Another example

Doctor: “And have you had any thoughts as to what might be going on?”

Patient: patient shrugs

Doctor: “For example, has someone said anything to you about it or have you read anything on the internet or a magazine?”

Patient: “Well I have to admit, I did do a bit of an internet search. I know you’re not suppose to but…”

ICE - Ideas, Concerns & Expectations

ICE – Ideas, Concerns and Expectations – What do trainees do so wrong?

I wanted to talk about his particular area and its accompanying scripts and phrases for a two particular reasons. Firstly, it is often badly done and secondly because the way many trainees do it is a way that CSA examiners don’t particularly like. But let’s not confuse the issue here. No matter what anyone says, there is nothing wrong with the concept of exploring “ICE”. At the end of the day, with ICE you are simply trying to find out what the patient is thinking, what they are worried about and what they are hoping for. So tell me, what’s wrong with that? THERE IS NOTHING WRONG WITH THAT. In fact, exploring ICE is a very patient-centred thing to do and it is in keeping with the ethical practice of treating the patient as an individual and respecting their views and thoughts (even if you don’t agree with them).

So why the anger towards ICE from CSA examiners and some patients?

The problem is not really about the concept of ICE. We have already established that it is a good thing to do. The problem lies with the way a lot of trainees do it. Many trainees see ICE as a rigid set of three tasks to be accomplished. And other people (like examiners and patients) will notice the fact that you’re trying to satisfy these three tasks rather than being truly and genuinely interested in the patient. Read these articles again if you haven’t already done so to see what I mean.

The problem with the rigid approach to ICE

So, most trainees simply think – I need to ask about ideas, concerns and expectations as soon as I can and then I have asked about it and then I get my three ticks. WRONG! WRONG! WRONG! Think about it… the whole purpose of ICE is to understand the patient’s position better. So asking each component at the right time is crucial.

Ask it too early for instance and the patient will not share their inner most delicate thoughts. Build some rapport and they will.

Also, try and ask about each of the components separately. Just because we group them together as ICE doesn’t mean we wish you to ask about them in succession, one after each other.

So ask in any order you like. But what is brilliant is if you can ask about each component at the most naturally right time to ask.

So for instance,

A patient might say: “Oh doc, these headaches are now really getting me upset and anxious”

and that might be the right time for the doctor to ask and say: “mmm…. I can see that. Are you anxious because you’re worried that they might be serious?”

Pt: “No, I’m not particularly worried they are serious”

Dr: “So, if you’re not worried that they are serious, had you any thoughts about what they might be? Or has anyone said anything to you about them or perhaps even something you have read about?”

Pt: “To be honest, I’ve just always thought they were migraines”

Dr: “And what made you think that?”

….and so the story goes.

In the next section, I'll write about the three ICE areas separately. The beginning of each section details the common ways in which GP trainees suboptimally phrase their questions. You may recognise some of them in the phrases you say. And if you have been on the receiving end of some of the undesirable responses from patients, then that is a sure sign that you have worded your question badly. The rest of the section then focuses on how to do it better. Remember, phraseology is everything.

Ideas

Bad Performance

Dr: “So, what do you think is going on?”

Pt: “I don’t know you’re the doctor”

(patient looks baffled, doctor feels stupid”

In this example, the doctor is wanting to know what the patient thinks, and that is a good thing. But the phrasing is bad. If you step in the patient’s shoes for a moment, it would be natural for them to thing “Why is this doctor asking me for a medical opinion when they are the qualified medical person, not me? How crazy!”. Can you see why the patient would look baffled?

So, how could you phrase this better?

“So, you’ve had this for x weeks now. Clearly it is bothering you. I’d be interested to know that in that time have you had any thoughts as to what it might be?” OR

“Before I ask you a few more medical questions to help me work out what is going on here, have you had any thoughts yourself as to what it might be?”

“Sometimes, patients have their own thoughts about what is going on. For example, friends and family members might have said something or alternatively they might have read something in a magazine. I’d be interested to know if you’ve had any such thoughts.”

Can you see that providing the reason for asking the question then helps the patient to understand the validity of your question. And they are ten times more likely to embrace it and respond in a positive way. In fact, as a general rule, remember, if you are asking or doing anything to a patient that might seem weird to them, explain the reason why you are doing. It saves a lot of aggravation in the end.

Concerns

Bad Performance

Dr: “Are you worried about anything?” OR “Have you any fears/concerns?”

Pt: “No, I’ve got nothing to worry about. Everything is fine at home and work and I haven’t got any financial problems if that’s what you mean”

Clearly a bad question. You and the patient are at cross wires. You want to find out if the patient has worries about what their symptoms might be – because you want to alleviate them – and that’s a nice thing to do. But the patient thinks you think it all might be a bit psychological. The patient then get’s internally annoyed with you and starts to lose faith. Again, this boils down to the fact that the patient cannot second guess the purpose behind your questions. You have to provide the reason!

Dr: “Are you worried about anything serious going on?”

Pt: “No. I just want it sorting doctor”

This is also bad question because it asks the patient if they are worried about something medically serious. But the patient might still have some other worries, like not being able to work or walk again (for example with back pains) rather than something life-threatening.

So, how could you phrase this better?

So in this instance, it would be better to say…

Dr: “Often when patients have had a problem for a little while, they start to worry about things it might be or it might do. So, you’ve had this problem for x weeks now. I’d be interested to know if you’ve any worries about your symptoms?”

In that way a patient might just say (eg for back pain) “I’m worried that might back is going to be like this for the rest of my life. I’m still young you know at 40 and I don’t want to not be able to work”.

Expectations

Bad Performance

Dr: “So, what would you like me to do about it?” OR “What were you expecting from me?”

Pt: “I don’t know, you’re the doctor”

(patient looks baffled again and you feel stupid).

So here, the patient and doctor are at cross wires again. The doctor is asking the question because they would like to know what the patient is hoping for and whether the doctor can satisfy those hopes because the patient will leave happy and the doctor will be happy. So, whilst the doctor’s intention in this case is good, the patient percieves it as something completely different. The patient thinks: “What a silly doctor – asking me what to do medically! I mean, they trained to be the doctor, surely they should know. If they don’t know should they be qualified and seeing patients like me? Mmmm I think I might go and see another doctor”

So, how could you phrase this better?

“So, thank you for coming to see me. Now that you’ve explained everything, can I ask what you were hoping I might do for you?” or…

“Thanks for explaining all that to me. I’ve got some thoughts in my own mind about where we go from her. But before I share them with you, I was wondering if you had thoughts of your own about what you were hoping we might do?”

Sometimes it might be obvious what the patient wants…

Dr: “So am I sensing that you were hoping I might do a back x-ray for your on going back problem? Have I got that right?

Pt: “Yes, and I was wondering if there were any blood tests I might need?”

And even if you get it wrong, that’s fine because the patient will provide the correct information and you will both be wiser.

Dr: “So am I sensing that you were hoping I might do a back x-ray for your on going back problem? Have I got that right?”

Pt: “No, not at all doc. I was actually wondering whether I needed to see a physiotherapist or a back specialist?”

PSO - Psycho Social Occupational

The psycho-social-occupational enquiry is something that I feel should be done routinely. Why? Because it helps you truly understand the impact of a disease on the patient’s life. This impact is what we call the ‘patient’s illness’.

So, an left leg sciatica = the DIS EASE

not being able to go upstairs, unable to walk, in pain all the time = the ILLNESS.

Why is the illness so important? Because the same disease can affect different people in different ways. Someone might have sciatica that they can put up with and don’t feel they want to take anything for because it only causes them a niggle. For others, it is devastating. Can hardly walk with it. In tears all the time. So can you see, if you just coded both as sciatica in the medical record, it doesn’t really give any flavour to how bad it is. So, by exploring the illness, you add FLAVOUR to the disease. At the end of the day, for most diseases, patients are bothered about the impact it has on their lives rather than the diagnosis itself.

And you explore the illness by exploring what impact the disease (or its symptoms) have on the patient’s…

social life (how does the disease interfere with functioning at home, with hobbies, with driving, with relationships, with social functioning etc.)

work life (what does it stop them doing at work)

mental well-being (the psychological impact of the disease on the patients mental well-being – is it getting them down, depressed, anxious, crying etc).

Exploring all three will give you a good idea about the ILLNESS. And the great things about exploring the PSO (Psycho Social Occupational) is that you can then use that information to further elaborate the history, the explanation and/or management plan.

Ex 1 – using it in the explanation – “Mrs X, Unfortunately, I think you’ve got something called sciatica, which is a trapped nerve in your buttock. The pain can be so bad that it stops you doing simple things like managing the stairs – as you have found out already”

Ex 2 – using it in the management plan – “Mrs X, you said earlier that the pain was so bad that it stopped you going out any more. And that there’s been several times a day where you’ve ended up crying. Would it help if I gave you something to help with the pain?“

Ex 3 – using it to elaborate the history further – “Mrs X, you said earlier that the pain was so bad that it stopped you going out any more. And there’s been several times a day where you’ve ended up crying. Can you tell me if your spirits have hit rock bottom?” (mood enquiry)

clip 1

In this first clip, see if you can understand and empathise with Jennifer’s story. Go ahead, press play and come back to this point.Did it evoke any emotion? If it does, that’s what stories actually do. They turn boring samey-samey diseases into colourful individual patient stories through their experiences. This makes us feel for our patients. And it makes us want to help them. And it helps us understand exactly how an disease has upset someone’s life and in knowing that information, perhaps we can help them better than just solely focusing on the disease and it’s clinical management.

clip 2

In the second clip, Dr Arora gives some wonderful advice for the CSA (which is also good for your daily practice.

Please leave a comment below if you have any words of wisdom to help others or if you have any questions you wish to ask…

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